Recently, the Surviving Sepsis Campaign released their 2016 guideline update. Overall, I think this iteration moves the guidelines closer to the best evidence out there. Of course, when you travel that path it forces a divergence from the distinctly non-evidence-based CMS guidelines. In this Practical Evidence Podcast, we will discuss the SSC guidelines, the aforementioned divergence, and various alcohol recommendations. I brought on my buddy, Jeremy Faust, to discuss the changes. Jeremy is 1/2 of the FOAMcast podcast which just discussed the new guidelines in a recent episode.

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Practical Evidence Helps You Keep Track of the Guidelines You Need to Know

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Alex (MD, Critical Care Unit – Hamburg)
I still wonder myself what does “unstable after the use of fluids and vasopressors” mean => the degree of freedom is quite big. i am planning to read those studies carefully and see at what NA dose they started the use of hydrocortisone.

I was asking because it occured to me… we have a Sepsis SOP where we are supposed to start Hydrocortisone when the NA dosage has reached really high values (more than 60µ/min). The studies citied in the SSC randomised patients who “were on vasopressors”, so what I understand is that they could have received Hydrocortisone both at small doses of NA and at higher doses, no difference. Only in HYPRESS there are some statements about inclusion criteria related on NA dosage, but basically all P who got NA and were septic received Hydrocortison…
It would be interesting to know if there are subgroups where Hydrocortison would have made some difference (small dosage NA vs high dosage NA).
SOPs can sometimes limit one’s clinical judgment ! What is your opinion, when do you start Hydrocortisone? Do you have some time limit, like, the patient has more than 12 h of NA therapy, then he needs Hydrocortisone…
Thanks for your answer.
Alex

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1 year ago

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Drew

What is the recommendation for using LR instead of NS in sepsis if trending the lactate is important? Does LR affect the measured lactate level?

Hey Mike, I’ll answer the SIRS question by saying that all of the evidence we have is that SIRS is *such* a wide net that it seems to capture both normal responses to infection (i.e. a perfectly healthy and appropriate one that shows that the body is doing what it supposed to do–fight infection) as well as dysregulated ones (i.e. maladaptive host response in which the body’s pro and anti inflammatory pathways are on overdrive and wreak havoc.) That is why SIRS is so sensitive but so TERRIBLY not specific. One way of looking at this is to look at Figure 1 of Jean-Louis Vincent’s article on SIRS and qSOFA. https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1389-z Caveat: while Dr. Vincent probably knows more about sepsis than I ever will, he’s missed the fine points of the data on how qSOFA performs..so you can ignore lot of what he says, actually. In fact, qSOFA outperformed even SOFA and SIRS in the ED setting in the original derivation paper. But it is the FIGURE in his article is what is important in terms of framework, which is what you should notice. In short, not all SIRS is sepsis nor is qSOFA. On the other hand, the recent… Read more »

To start (at least in an ALS-based EMS system, or one with ALS-intercept availability), EMS should not be transporting cardiac arrest patients to the hospital (unless there are extenuating circumstances: refractory VT/VF, pregnancy >20 weeks, hypothermia, etc.). I agree with your thoughts and highly promote the idea of dual-sequential defibrillation, along with the ideas behind mechanical CPR. From an EMS standpoint (as a Paramedic), many agencies simply can’t afford mechanical devices…so we’re stuck with old-school practices. Meds and defibrillation, however, our trends are changing to promote cardiac arrest as a “stay and play” type of event, rather than “load and go.”

I think you will see the trends swinging back the other way. What I can do in the hospital for these patients is dramatic. I think you will see in non-MD systems a move towards early transport for all but unsurvivable cases.

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1 year ago

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Andrés von Wernitz

Andrés von Wernitz (MD Emergency Department, Madrid, Spain)

Maybe I’m not catching the correct sense of the new guidelines (or the 2012 ones) but here is my question: is there a change in the definition of sepsis-induced hypoperfusion ?

Does it means that in 2012 to state that someone had sepsis-induced hypoperfusion it was necessary to first preload with the mysterious amount of 30cc/kg fluid and then confirm hypotension or lactate concentration ? 4 mmol/L and now on it is sufficient that someone presents with suspected infection and delta SOFA > 2 to defining sepsis-induced hypoperfusion (without no initial fluid infusion and not presenting hypotension and lactate > 2, i.e. Bilirubin of 3 mg/dL)?

Thanks for your answer.

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1 year ago

Guest

Luke

As a paramedic the only pressor i have available is dopamine. Is it still worth giving if it is the only option?

With no lactate in the field we look at EtCO2.
EtCO2 less than 25 in suspected sepsis pt =high likelihood of elevated lactate. And it is an instantaneous measure.

I believe the guidelines say lactate greater than 2 is septic shock! That doesn’t make sense

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1 year ago

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Taylor Sanders

What the fuck do I do with cirrhosis (albumin 2.3), elevated lactate without shock, large transudative pleural effusion, anisocoria. Had good response with initial crystalloid of 1000ml (15ml/kg) then gave albumin followed by D5 1/2 (due to persistent hypoglycemia) at 250ml/hr. I know it says only consider albumin for fluids needed after initial 30ml/kg… but the studies I’ve seen comparing initial fluid types indicate there’s only no benefit (but no harm), using albumin sooner. And these same studies don’t seem to provide subanalyis for cirrhotic or liver failure patients.
BTW… heard of your podcast but recently started listening. Change my life. I have completely given up store bought drink mixers.
What’s your approach for intravascular volume depleted, significantly third spaced, septic patients with impaired organ perfusion requiring fluids?